State of New Jersey
New Jersey Commission on Science and Technology
SBIR Bridge Grant Program
Application
Section 1 - Applicant Information:
Applicant/Primary Contact Person:
Applicant/Primary Phone Number:
Secondary Contact:
Secondary Phone Number:
Applicant/Primary Contact Email
Secondary Contact Email
Company Name (full legal name):
Address:
Website Address:
Fax Number:
Company Phone Number:
City/State/Zip:
Tax I.D. Number:
Principal Place of Business (Address):
Municipality:
City/State/Zip:
Total Number of Employees:
Number of Employees Living Number of Full-Time
in NJ:
Employees:
State of Incorporation:
Month of Incorporation:
Most recent two fiscal year’s revenues:
Year of Incorporation:
Last Fiscal Year 200__
Previous Fiscal Year
___________________
_________________
For each employee, please provide place of residence, municipality, county, and state. Attach additional
sheets if necessary.
Employee Name
Municipality
County/State
Hours
Worked
Per Week
Employee
Type – W-2,
1099, other
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New Jersey Commission on Science and Technology
SBIR Bridge Grant
Section 3 – Budget:
SBIR Bridge Grant Program
Standard Budget Formats
Anticipated Expenditures
CATEGORY
NJCST FUNDING
OTHER FUNDING
SOURCES
Personnel
Salaries & Wages (itemize by category)
Fringe Benefits
Consultants (itemize)
Travel
Supplies (itemize)
Equipment (itemize)
Other Direct Expenses (itemize by category)
TOTAL ANTICIPATED EXPENSES
Notes:
1 A brief narrative describing budget items must be provided.
2 Please provide a single summary expenditures budget, in the above format, which summarizes all anticipated program expenditures for
the grant period.
3 If the program involves multiple projects or teams, please provide a separate detailed expenditures budget, in the above format, for each
project or team. The sum of these detail budgets should equal the summary expenditures budget.
4 If the grantee will issue subcontracts to other participating organizations, please provide a separate detailed expenditures budget, in the
above format, for the prime contract, and for each subcontract. The sum of these detail budgets should equal the summary expenditures
budget.
5 Other funding sources maybe broken down into the following categories: university, federal, and industrial
6 The budget may not include any indirect expenses
________________________________________________________________________________________ 3
New Jersey Commission on Science and Technology
SBIR Bridge Grant
Section 4 – SBIR/STTR Information:
Federal Department / Agency Name:
Topic/Sub Topic Name:
Topic Number (if applicable):
Project Title:
University Partner (if applicable):
Phase I Application Submission Date:
____________________________________________________
Phase I Award Amount:
Phase I Award Date:
____________________________________________________
Phase II Application Submission Date:
Requested Phase II Fund Amount:
____________________________________________________
Date Received Phase II Letter of Intent:
(Please list the date that you received official letter from federal agency identifying you as a potential awardee)
Anticipated Phase II Award Date:
____________________________________________________
(Please list the date that you expect contract award from the federal agency)
Section 4 Attachments
 A copy of the award letter from a federal agency notifying the recipient of the Phase I
SBIR/STTR award
 A copy of the Phase II proposal/application cover letter/sheet
 A copy of the official letter of intent to negotiate a Phase II award (the official letter of intent
must be on agency letterhead and must dictate that you are being considered for Phase II
funding)
 A numbered list of all previous SBIR awards (Phase I, II) from all federal granting agencies
Section 5 – Workplan (no more than 5 pages)
Please attach a brief workplan describing the use of the NJCST Bridge Grant with detailed milestones
of how the Bridge Grant will be used
Section 6 – Gantt Chart
Attach a simple Gantt chart showing the proposed milestones
Section 7 – Verification of Annual Revenue
Attach an audited financial statement [using generally accepted accounting principles (GAAP basis)] including
balance sheet, income statement and cash flow statements OR a current corporate tax return and a non-audited
financial statement including balance sheet, income statement and cash flow statements for the applicant, its
parent and subsidiary companies
________________________________________________________________________________________ 4
New Jersey Commission on Science and Technology
SBIR Bridge Grant
Section 8 – Eligibility and Disclosures
Have any of the persons or entities listed above:
been, within the last five years, a party in litigation?
Yes
No
been, or is now, charged with, convicted of, under indictment, on parole, on probation or a plaintiff, defendant or other
party in, any criminal or civil offense other than a minor motor vehicle violation?
Yes
No
been, or is now, subject to, or has pending, any disciplinary action by any administrative, governmental or regulatory body?
Yes
No
been, or is now, subject to any order resulting from any criminal, civil or administrative proceedings brought against such
persons or parties by any administrative, government or regulatory body?
Yes
No
been, or is now, denied any license by any administrative, government or regulatory agency on the grounds of moral
turpitude?
Yes
No
been, or is now, informed of any current or on-going investigation with respect to possible violation by such persons or
parties of state or federal securities, anti-trust or criminal laws?
Yes
No
been, or is now, denied a business or professional-related license or had it suspended or revoked by any administrative,
government or regulatory agency?
Yes
No
been, or is now, disbarred, suspended or disqualified from contracting with any federal, state or municipal agency?
Yes
No
been, or is now, in receivership or adjudicated bankrupt?
Yes
No
been, or is now, in default on a personal or business loan?
Yes
No
is now involved in any pending lawsuits?
Yes
No
If the answer is “yes” to any of the questions above, furnish details on a separate page under the heading
“ELIGIBILITY AND DISCLOSURES”. Any information you wish to submit that may expedite this
investigation should be set forth as an attachment.
________________________________________________________________________________________ 5
New Jersey Commission on Science and Technology
SBIR Bridge Grant
Section 9 – Application Affidavit
I, THE UNDERSIGNED, BEING DULY SWORN UPON MY OATH SAY:
1. I affirm, represent and warrant that the information contained in this application and all attachments
submitted herewith is true and complete to the best of my knowledge and that the grant applied for
herein is not for personal, family or household purposes.
2. I understand that if such information is willfully false or eligibility for the Commission Bridge Grant
is falsely certified I am subject to criminal prosecution under N.J.S.A. 2C:28-1, 2C:28-2 and 2C:28-3,
as applicable and civil action by the Commission which may at its option terminate its grant.
3. I authorize the New Jersey Department of Law and Public Safety to verify any answer(s) and
information contained herein through a search of its records or records to which it has access and to
release the results of said research to the Commission.
4. I authorize the Commission to obtain such information including, but not limited to, a credit bureau
check as it may require, covering the applicant and/or its principals.
5. I understand that the Commission will retain this application and all associated documents, whether
or not this application is approved.
_______________________________________________
Signature of Applicant
________________________________________________
Name and Title of Applicant (Print or Type)
_________________
Date
Sworn and Subscribed before me this ___ day of
___ 20__
________________________
NOTARY PUBLIC
________________________________________________________________________________________ 6
New Jersey Commission on Science and Technology
SBIR Bridge Grant
Section 10 – Public Project Description
Provide a Public Project Description in plain lay language of the proposed project and company. Do
not include proprietary or confidential information because, if the application is funded, this
information will be made public.
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I certify that all information that I have provided in this application is correct to the best of my knowledge. I understand that the
Commission will retain this application and all associated documents, whether or not this application is approved. I understand that the
Commission may obtain a credit report concerning the applicant firm.
I understand that deliberately making false statements on this application, or falsely certifying eligibility for the Commission Bridge
Grant is prohibited under Section 2C:28-3 of the New Jersey Code of Criminal Justice, and is punishable by fine or imprisonment.
________________________________________________________ _____________________________________________________
Signature of Applicant
Date
Name and Title of Applicant (Print or Type)
________________________________________________________________________________________ 7
New Jersey Commission on Science and Technology
SBIR Bridge Grant
SBIR Bridge Grant Application Checklist
Before submitting your proposal, please use the checklist below to insure completion of the application
Have received no more than 10 federal SBIR’s previously
Application Forms – Section 1&2
Summary Budget – Section 3
A copy of the award letter from a federal agency notifying the recipient of the Phase I
SBIR/STTR award – Section 4
A copy of the Phase II proposal/application cover letter/sheet – Section 4
A copy of the official letter of intent to negotiate a Phase II award – Section 4
Numbered list of previous SBIR Phase I & Phase II awards – Section 4
Work Plan – Section 5
Gantt chart – Section 6
Financial Statements – Section 7
Eligibility and Disclosures Form – Section 8
Application Affidavit – Section 9
Public Project Description – Section 10
________________________________________________________________________________________ 8
New Jersey Commission on Science and Technology
SBIR Bridge Grant
Application Submission
Send the original signed copy of the Application and the complete Grant Proposal on a CD in PDF format
to the Commission at the address below.
Overnight:
New Jersey Commission on Science and Technology
SBIR Bridge Grant Program
10 South Montgomery Street
Trenton, NJ 08625
U.S. Postal Service:
New Jersey Commission on Science and Technology
SBIR Bridge Grant Program
P.O. Box 832
Trenton, NJ 08625
NOTE: Incomplete applications on the due dates may result in the proposal not being reviewed or considered.
PowerPoint presentations will NOT be accepted as part of the application package.
For Additional Information
Please contact the New Jersey Commission on Science and Technology at (609) 984-1671 or
njcst@scitech.state.nj.us.
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New Jersey Commission on Science and Technology
SBIR Bridge Grant